Basic Information
| Provider Information | |||||||||
| NPI: | 1588952972 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANAVAN | ||||||||
| FirstName: | MARYANNE | ||||||||
| MiddleName: | COLLEEN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1457 CLOVE VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | LAGRANGEVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125406437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155159748 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1275 YORK AVE | ||||||||
| Address2: | ZUCKERMAN 4TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100656007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126392000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2011 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 30 305725 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.